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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 183 FOREST STREET 2/10/2022 RECEIVED Commonwealth of Massachusetts FEB 10 2022 City/Town Of North Andover System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 183 Forest Street Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Dennis & Susan Holland Name 183 Forest Street Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9786861681 Telephone Number B. Pumping Record 1. Date of Pumping 10/25/2021 2. Quantity Pumped. 1500.0000 Date Gallons 3. Component: Cesspool(s) © Septic Tank ❑Tight Tank ❑Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ©Yes D No If yes, was it cleaned? ©Yes ❑ No 5. Observed condition of component pumped: System o t g F o Narmal Wateri i na a rate top solids Moderate hattom - been­ cleaned as needed. Cover s secured. Removed 1500 gallons. Recommended Boost additive,CCLS additive. 6. System Pumped By: Robert Herrick Name Vehicle License Number Wind River Environmental, LLC, 577 Main Stre*t, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA 10/25/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1